Current Trends
Heterosexual Behaviors and Factors that Influence Condom Use
among Patients Attending a Sexually Transmitted
Disease Clinic -- San Francisco

Because the incidence of human immunodeficiency virus (HIV)
infection and other sexually transmitted diseases (STDs) is lower
among persons who use condoms regularly, the Public Health
Service has promoted the consistent and proper use of condoms by
sexually active persons (1). In San Francisco, rates of HIV
infection and other STDs among white homosexual men have
decreased dramatically since 1982 (2,3); this decrease has been
attributed to the use of condoms and the adoption of other sex
practices that reduce the risk for transmitting and acquiring
these infections. At the same time, however, the incidence of
syphilis and other STDs has increased among heterosexuals,
especially among minorities (2). This report summarizes findings
from a study of heterosexual behaviors and factors that influence
condom use among men and women attending an STD clinic in San
Francisco.
From October 1 through December 31, 1989, every 10th man and
every second woman entering the clinic for care was asked to
participate in the study. After obtaining informed consent, an
interviewer administered a standardized questionnaire. Patients
asked to enroll in the study were 18-65 years of age and reported
having had sexual intercourse with a member of the opposite sex
within the previous 12 months; 341 were enrolled, including eight
men and 11 women who reported having had sexual intercourse with
members of both sexes. Persons who reported exchanging sex for
money or drugs were also included in the survey. To minimize
recall bias, data from those who had not had sexual intercourse
with a member of the opposite sex within the previous 2 months
were excluded from the final analysis (n=41).
The 341 patients (162 men and 179 women) enrolled in the study
ranged in age from 18 to 64 years (mean: 28 years); 88 (54%) of
the men and 90 (50%) of the women were either black or Hispanic
(Table 1). One hundred fifty-six (46%) reported annual incomes
less than $5000. Overall, 149 (46%) of 325 patients were newly
diagnosed with an STD on the day of the interview (61 (39%) of
155 men and 88 (52%) of 170 women); diagnoses for the remaining
16 were unknown.
Of the 341 patients, 133 (82%) men and 142 (79%) women knew
that HIV could be transmitted through vaginal and anal
intercourse and by sharing needles during intravenous (IV)-drug
administration; 157 (97%) men and 171 (96%) women knew that
regular condom use could reduce the likelihood of acquiring HIV
infection.
In the final analysis, nearly all (292 (97%) of 300) patients
reported they had used a condom sometime in the past (Figure 1):
245 (82%) at least once in the previous 12 months and 180 (60%)
at least once during the 2 months before the interview.
Seventy-six (25%) reported they had used a condom when they last
had intercourse; these patients were less likely to be diagnosed
with an STD on the day of the interview (relative risk (RR)=0.6;
95% confidence interval (CI)=0.4-0.9, Mantel-Haenszel chi-square
test). This association did not vary by their reasons for the
clinic visit. Condom use at last intercourse was reported by five
(14%) of 36 Hispanics, 20 (16%) of 126 blacks, and 41 (37%) of
112 whites (p less than 0.001, chi-square test).
Among men, the likelihood of using a condom at last
intercourse was lower for those who reported 1) they had used
alcohol or other drugs at last intercourse (RR=1.3; 95%
CI=1.1-1.5); 2) they would not use a condom if they were "in
love" with their partners (RR=1.2; 95% CI=1.1-1.5); 3) they
experienced difficulty in communicating with their partners about
condoms (RR=1.3; 95% CI=1.1-1.5); and 4) their partners did not
want to use condoms (RR=1.4; 95% CI=1.1-1.8).
Among women, condom use at last intercourse was lower for
those who 1) were black (RR=1.3; 95% CI=1.1-1.6); 2) reported
that condoms decrease sexual pleasure (RR=1.5; 95% CI=1.2-1.8);
3) reported that they would not use a condom if they were "in
love" with their partner (RR=1.3; 95% CI=1.1-1.5); and 4)
reported that their partners were unwilling to use condoms
(RR=1.5; 95% CI=1.1-2.0).
Several variables were not statistically associated with
condom use, including patients' prior STD history, age, income,
education, total number of sex partners, perceived risk for HIV
infection, knowledge about HIV transmission and condom
effectiveness, peer endorsement of condoms, and acquaintance with
someone with acquired immunodeficiency syndrome (AIDS); whether
patients engaged in vaginal or anal intercourse; and whether
patients exchanged sex for money or drugs.
Based on multivariate analysis controlled for age, race,
income, number of sex partners, and other variables (Table 2),
condom use was lowest among men who had used alcohol or other
drugs at their most recent sexual intercourse and men who stated
that their partners did not want to use condoms. Condom use was
lowest among women who reported that their partners did not want
to use condoms, believed condoms reduce sexual pleasure, reported
having had sex with a steady partner, or were black.
Overall, 30 (27%) of 113 men and 41 (31%) of 132 women who had
used condoms during the previous 12 months reported at least one
episode of condom breakage. Rates of condom breakage in the
previous 2 months were calculated as the proportion of times
condoms broke while being used during vaginal or anal
intercourse. The breakage rates for condoms during vaginal and
anal intercourse were 4.3% and 4.2%, respectively. However,
condom use was reported for only 24 episodes of anal intercourse.
Reported by: C Lindan, MD, S Kegeles, PhD, N Hearst, MD, P Grant,
D Johnson, Center for AIDS Prevention Studies, Univ of
California, San Francisco; G Bolan, MD, San Francisco Dept of
Public Health; GW Rutherford, III, MD, State Epidemiologist,
California Dept of Health Svcs. Div of Sexually Transmitted
Diseases and HIV Prevention, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: Because the San Francisco STD clinic emphasizes
health education and distributes condoms free of charge, the
participants in this study may have overstated their use of
condoms despite being assured of confidentiality. This study
focused on patients' last episode of sexual intercourse because
less recall was required and because patients who used condoms at
that time were less likely to be diagnosed with an STD on the day
of the interview. Nonetheless, the interpretation of these
findings may be limited by recall and reporting bias.
In this study population, overall reported condom use was low.
Although infrequent use of condoms can be expected in an
STD-patient population, substantial differences were reported in
condom use between whites and minorities. These data also
indicate lower condom use among women who had sex with "steady"
partners than among those with casual partners--a finding
consistent with studies among homosexual male partners (4),
female prostitutes (5), and women attending reproductive health
clinics (6).
Patient reports of condom use decreasing sexual pleasure are
consistent with other reports among homosexual men and IV-drug
users (7,8), although in this study the association of this
variable with not using a condom was statistically significant
only among women. Other factors associated with lower condom use
reported in this study included lack of partner endorsement of
condoms and use of alcohol or other drugs at the time of sexual
intercourse, which are consistent with findings in other
population groups (7-9).
Condom breakage generally has been reported in association
with anal intercourse among homosexual men. In the STD-patient
population in this report, a large proportion of heterosexual men
and women reported condom breakage during vaginal intercourse;
this finding is consistent with a previous study of heterosexual
men and women attending a genitourinary medicine clinic in London
(10). In San Francisco, however, the breakage rates were higher
than those reported by prostitutes in a prospective study in
Australia (0.5% breakage during anal intercourse; 0.8%, vaginal
intercourse) (11). Factors related to condom breakage may include
improper use, improper storage, or poor manufacture.
Data from this study and another ongoing study of patients'
sex partners will be used by the San Francisco Department of
Public Health and collaborating organizations to develop and
evaluate interventions to increase condom use.

References

CDC. Condoms for prevention of sexually transmitted diseases.

MMWR 1988;37:133-7.

2. San Francisco Department of Public Health. Syphilis and
congenital syphilis in San Francisco. San Francisco Epidemiol
Bull 1990;6:1-6.

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